Male circumcision and global HIV/AIDS epidemic challenges

Abstract

Background: Given the devastating mortality and morbidity associated with HIV/AIDS, many potential prevention measures against HIV infection continue to be explored. Most prevention methods are in the realm of sexual behavior change. However, of all aspects of human behavior, it is sexual behavior that is least amenable to change. Newer and simpler interventions are therefore required. Male circumcision, the surgical removal of some or all of the foreskin (or prepuce) from the penis, is one of the ways being promoted as a preventive measure. This paper reviews the scientific basis and evidence for the efficacy of male circumcision within the context of the global challenges involved. Main body: We reviewed articles with emphasis on male circumcision and HIV/AIDS transmission. Published abstracts of presentations at international scientific meetings were also reviewed. Conclusions: Current epidemiological evidence supports the promotion of male circumcision for HIV prevention, especially in populations with high HIV prevalence and low circumcision rates. Three notable randomized control trials strengthen the case for applied research studies to demonstrate that safe male circumcision is protective at the population level, particularly as ideal and well-resourced conditions of a randomized trial are often not replicated in other service delivery settings. Ethically and culturally responsive strategies in promoting circumcision in a culturally heterogenous world need to be developed, too. Male circumcision should also be viewed as a complementary measure along with other proven approaches to turn the HIV/AIDS epidemic around.

Circumcision and its effects in Africa

“…Circumcision, although free of complications in the majority of patients, often results in untoward consequences such as excessive or inadequate skin removal, pain, haemorrhage, wound infections, skin bridge, meatal stenosis, meatal ulcers, loss of penile sensitivity, urethrocutaneous fistula, sexual dysfunction and penile amputation ( 2 - 4 , 66 ).…”

“…Serious adverse events have been reported in 0% to 2.1% of circumcisions performed in neonates and infants ( 3 , 4 ). More commonly encountered, however, are minor complications such as redundant skin or excessive skin removal.…”

“…The procedure is performed on about a quarter to one-third of the world population of males ( 2 , 3 ). Male circumcision is performed at various ages—from neonatal period to adulthood ( 4 ). Religious and cultural beliefs have largely influenced neonatal circumcision with many adherents of Judaism and Islam adopting the practice ( 1 ).…”

“…There has been renewed interest in adult male medical circumcision as part of attempts to control the human immunodeficiency virus (HIV) pandemic in regions with low circumcision rates in sub-Saharan Africa ( 4 , 19 , 20 ). Randomized controlled trials have shown a significant reduction in HIV incidence among circumcised men with intention to treat efficacy and as-treated efficacy of 51% and 60% in Rakai, Uganda ( 21 ), 60% and 76% in Orange Farms and surrounding areas in South Africa ( 22 ) and 53% and 60% in Kisumu, Kenya ( 23 ) respectively.…”

“…Randomized controlled trials have shown a significant reduction in HIV incidence among circumcised men with intention to treat efficacy and as-treated efficacy of 51% and 60% in Rakai, Uganda ( 21 ), 60% and 76% in Orange Farms and surrounding areas in South Africa ( 22 ) and 53% and 60% in Kisumu, Kenya ( 23 ) respectively. This benefit of circumcision has been attributed, partly, to the removal of the foreskin, which is rich in HIV-1 target cells ( 4 , 21 , 24 , 25 ) as well as the inner mucosa of the foreskin being thin, non-keratized and vulnerable to HIV infection ( 4 , 21 , 26 ). The increased incidence of genital ulcers in uncircumcised men and minute tears resulting from sexual intercourse could equally encourage viral invasion ( 21 , 26 , 27 ).…”